Cognitive-Behavioral Approaches in Substance Abuse Treatment: Effective Practice ICCA – September 2012 Randy Shively, Ph.D. Alvis House: Columbus,Ohio

Open Eyes- Poem

Understanding our Own Patterns of Behavior can be the Beginnings of Change!!!

Wisdom from on High

Do not conform any longer to the pattern of this world, but be transformed by the renewing of your mind.

Drugs of Abuse-11 Classes

Caffeine; Cannabis; Cocaine; Hallucinogens; Inhalents; Nicotine; Opioids; Phencyclidine (PCP); Sedatives; Hypnotics; Anxiolytics DSM-IV

Addictive Medications/Toxins Antihistamines; Antihypertensive; Cardiovascular Medication; Antiparkinsonian Medication; Steroids; Chemotherapy Agents; Muscle Relaxants; Antidepressant Medications; Anti-inflammatory Medications DSM-IV

Corrections Clients Highly Susceptible-Why? • Lifestyles promote addiction • Environmental Supports (using friends, availability, high conflict neighborhoods)

• High risk/ need clients

Corrections Clients Susceptible

• Family Use • Learned way to cope with stressors • Justification in thought process

Quote “ Treating addiction(s) is not nearly enough if thoughts and behaviors behind the addiction(s) are not aggressively and systematically addressed” Randy Shively

Who Switched Off my Brain

“ A massive body of research collectively shows up to 80% of physical, emotional, and mental health issues today could be a direct result of our thought life” Caroline Leaf, 2009

Quote

“ It is not the drugs or alcohol per se which keep addictions alive, but the self serving thoughts and behaviors which the addict keeps telling himself” Randy Shively

Self Serving Thoughts • “I need to get high to perform my best” • “I am more alert on the job when I pop the pills” • “My kids are not hurt by my use because I never use in front of them”

• “ A few extra pills usually help calm my nerves

Plasticity of Brain The brain has incredible potential to change and grow new routes and connections just as a result of new thoughts

Basic Principles of CBT • Scientific (empirical support for strategies) • Action –oriented (ie. social skills,role play) • Focused on the present • Focused on learning (new behaviors) Speigler and Guevremont, 2010

Principle of Self-Reinforcement Cognitive and Behavioral changes reinforce each other- cognitive changes lead to changes in action and behavior which increases a person’s sense of wellbeing which strengthens the change in thought which strengthens behavior change

CBT Works

Andrews and Bonta, 2010

Common Language Important • Self Centered • Minimizing/Mislabeling • Blaming Others • Assuming the Worst Equip (Gibbs, Potter, Goldstein)

Substance Abuse is Secondary Need Area Criminal Attitudes and Behaviors and Peer Associations are Primary Needs and Substance Abuse, Employment, Financial, Family and Social Supports are Secondary Need areas Ohio Risk Assessment System, UC Research (Latessa)

Risk Principle

The Highest risk clients need the highest doseage of treatment (cog based). The lower risk clients need little treatment and needless treatment can raise their risk Lowenkamp and Latessa,2004

Risk Principle • Need to separate high risk from low risk in treatment and physically as much as possible

• Low risk clients can learn “criminogenic behavior” from high risk clients

How Much is Enough? Prison Study- Bourgon and Armstrong, 2006 620 Incarcerated males (moderate, high risk) Doseage: 100 hours, 200 hours, 300 hours

Results • One year follow-up viewing recidivism as re-incarceration • 100 hours sufficient to lower recidivism for moderate risk, no effect on high risk • 200 hours sufficient for high risk or multiple needs but not both • 300 hours sufficient for both high risk and multiple needs

Implications for Community Corrections • Does treatment in prison count toward the • •

doseage? How much is enough in community given less control of clients? How can cog based services be used in nontraditional ways? ie. Case management How accurate is our measure of risk given the doseage importance?

Key Components of Effective Treatment • • • • • •

Cognitive Re-structuring Social Skills Problem Solving Relapse Prevention Regulating Emotions Enhancing Motivation

University of Cincinnati Corrections Institute-SA Curriculum

Cognitive Based Curriculum

Cognitive Behavioral Intervention for Substance Abuse

University of Cincinnati Corrections Institute- See handouts

Cognitive Re-structuring • Links problem thoughts with problem behaviors

• Identifies risky thoughts • Implements new thinking in high risk situations Bush, Glick, Taymans, 2011

Example-Joe Joe’s self centered thinking allows him to use his paycheck to buy alcohol instead of paying family bills. His risky thoughts are wanting to drink with friends at bar, blaming his wife for his unhappiness, and getting money that he wants to spend now. Joe role plays receiving his paycheck and thinking of consequences, saying no to bar friends and spending time with family

Cognitive Re-structuring Exercise

Behavior Chain Group Exercise (2-4)- UC Curriculum

Social Skills

Goal is to learn new pro-social behaviors that compete with desire to use drugs and alcohol, cope with cravings, and manage thoughts about drug abuse. UCCI

Skill Cards-Steps • Beginning Skills: Listening, Starting a Conversation, Having a Conversation, Asking a Question, Saying Thank You

• Advanced Skills: Asking for Help, Expressing your Feelings, Dealing with Fear, Using Self Control Goldstein and McGinnis, Research Press

Listening as a Skill-Steps • Look at the Person who is talking • Think about what is being said • Wait your turn to talk • Say what you want to say

Dealing with Fear 1. Decide if you are feeling afraid 2. Think about what you might be afraid of 3. Figure out if the fear is realistic 4. Take steps to reduce your fear

Group Process • Group leader models skill to learn • Select 2 members to role play skill • Assign a step of skill to each “observing group member”

Group Process • Perform role play (right way) • Feedback from all of group • Assign practice of skill outside of group

B. Social Skill Practice • Listening- Role Play- See handout

• Dealing with Fear- Role Play- See handout

Problem Solving • Calm emotions and delay instant gratification

• Teach a model of steps to follow

Problem Solving Steps 1. Stop and Think 2. Identify Problem Objectively 3. Identify a Goal 4. Brainstorm Options 5. Link Options to Outcomes

Problem Solving Steps, Cont’d 6. Choose best Option and make a Plan 7. Take Action 8. Evaluate

Problem Solving • Practice in lower to high risk situations • Role play thinking through the process, ie. You are tempted to go to a party with friends where drugs will be used; you get bad news and want to get high; a parent keeps not believing that you can stay clean.

C. Problem- Solving Exercise 1.

2.

Group Process (5-4) – UC Curriculum “Friend invited me to a Party”

Role Play the situation

Make Learning Fun • Equipped for Life Game- Horn, Shively, and Gibbs

• Thinking Error Jeopardy • Equip Basketball (Horse, Pig)

Relapse Prevention -8 Steps 1. Identify high risk situations that have led to current risky lifestyle

2. Review behavior chain ( thoughts, feelings, actions) for each high risk situation 3. Create a plan for coping with risky situations, thoughts, and feelings using learned Pro-social skills Canadian Research

Relapse Prevention – 8 Steps 4. Life history and lifestyle factors that have influenced risk to engage in substance abuse 5. Identify current lifestyle factors that need to stop and healthy lifestyle factors to develop 6. Identify warning signs of Lapse and plan for a getting back on track

Relapse Prevention- 8 Steps 7. Identify support systems to help with healthy lifestyle

8. Create a plan for how to transfer skills learned into everyday life

D. Group Process- Relapse Prevention

• UC Curriculum- Steps 1 and Step 2- See Handouts

Regulating Emotions

Learning appropriate skills in dealing with uncomfortable intense emotions linked with using substances (ie. rage, fear, depression)

Teach Strategies • Self Control • Dealing with urges • Managing anger, stress, anxiety • Dealing with fear and rejection UCCI

Regulating Emotions Must learn to recognize and name unpleasant feelings first

Role play skills in dealing with unpleasant bodily feelings related to substance abuse situations

E. Group Work- Regulating Emotions

• Self-Control Strategies- UC Currriculum (3-12)- See Handouts

Enhancing Motivation

• Must spend time weighing the pros and cons of continued use

• Clarify values that support non-use • Set life goals opposed to using

F. Group Exercise: Enhancing Motivation • Weighing the Pros and Cons • Benefits of Change See Decisional Balance Worksheet

Stages of Change

Educating clients to a Stages of Change model helps the client and the staff better understand where the client is and isn’t in the change process!!!

Assessment of Change

University of Rhode Island Change Intrument (URICA) measures the stage of change for each client- why provide treatment if client is not ready for it?

Switching On the Brain

Replacing toxic thoughts with healthy ones are neurochemical events where thoughts and feelings get changed and the brain can be significantly altered Dr. Caroline Leaf

Switching On the Brain • Gather • Reflect • Journal • Revisit • Reach

Gathers

Through brain sweeping exercises the client can learn to control incoming information and get rid of what they do not want before it gets wired in the brain and affects who they are

Gather- Equip Language • Think of the Consequences (TOC) • Think of other People (TOP) • Check Yourself • Minimize your Risk • Use Self Talk

Reflect • Goal is awareness of negative thinking • Mental practice research has shown produces the same physical changes in the brain as it would physically carrying out the imagined practices

• Deep thinking exercises over 21 days can create long lasting changes in the brain

Journal • Creatively writing down thoughts switches on brain

• Creative note taking helps memory retention- changes thoughts/ changes brain

Revisit • Revisiting what journaled and what reflected on sets up new circuits/connections in the brain

• Thoughts can be re-designed when they are consciously captured and focused

Reach • Practice reaching beyond where you are in thinking

• Words, thoughts, and actions become more congruent and integrated

Brain Sweep Questions

Dr. Leaf presents Brain Sweep Questions over problem areas called the Dirty Dozen

Dirty Dozen • Toxic Thoughts ( Thinking Errors) • Toxic Emotions ( Pride, Anger, Self-pity) • Toxic Words ( Powerful to Hurt) • Toxic Choices ( Irresponsible, poorly thought out)

Dirty Dozen • Toxic Dreams ( Remembering is key) • Toxic Seeds ( Unforgiveness) • Toxic Faith ( Ignoring need for faith) • Toxic Love ( No connectedness with others)

Dirty Dozen • Toxic Touch ( Touch Deprivation) • Toxic Seriousness ( Lack of laughter, fun) • Toxic Health ( Little exercise, poor habits) • Toxic Schedules ( Hurry sickness, won’t slow down)

Brain Power

Our brain is so powerful- no thought is harmless nor does any thought stay the same. Healthy thoughts affect the whole body and impact emotions and behaviors

Summary • Need to know risk of client • Need evidenced based curriculum • Need a lot of practice in problem solving and social skills

• Need committed staff that form vital relationships with clients and know Cognitive approaches well

References Andrews, D. and J. Bonta. 2010. The Psychology of Criminal Conduct (5th edition). Cincinnati, Ohio: Anderson Publishing Co. Beck, A. and F. Wright, C. Newman, and Liese,B. 1993. Cognitive therapy of substance abuse. New York, NY: Guilford Press. Bourgon,G. and B. Armstrong. 2006. Transferring the principles of effective treatment into a “real world” setting. Criminal Justice and Behavior, 32(1):3-25.

References, cont’d Gibbs, J., B. Potter, and A. Goldstein. 1995. The Equip Program. Champaign, Illinois: Research Press Goldstein, A., and McGinnis, E. 1997. Skillstreaming the

Adolescent: New Strategies and Perspectives for Teaching Prosocial Skills (Cards). Champaign, Ill: Research Press. Horn, M., R. Shively, and J. Gibbs. 2005. Equipped For Life Game. Westport, CT: Franklin Learning Systems. Leaf, C. 2009. Who Switched Off my Brain. Southlake, Tx: Inprov,Ltd.

References, Cont Lowenkamp, C. and E. Latessa. 2004. Increasing the effectiveness of correctional programming through the risk principle: indentifying offenders for residential placement. Criminology and Public Policy, 4(1): 501-528. Luther,J, et.al. 2011. Cognitive Behavioral

Interventions for Substance Abuse (curriculum).

University of Cincinnati Corrections Institute. Milkman, H. and K. Wanberg. 2007. Cognitive

Behavioral Treatment: A Review and Discussion for Correctional Professionals. NIC.

References, Cont Prochaska, J. and C. DiClemente. 1982. Transtheoretical therapy: toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3): 276-288. Speigler, M. and D. Guevremont. 2010.

Contemporary Behaviour Therapy. (5th Edition). Pacific Grove, CA: Brooks/Cole.